DEPARTMENT OF CHILDREN AND FAMILIESAdoption Records Search Program

Division of Safety and PermanencePO Box 8916

Madison, WI 53708-8916

(608) 266-7163

Family History Questionnaire

Medical / Genetic – Pregnancy and Delivery Information

Use of form: This form is used to collect pregnancy and delivery information for any child whose biological mother has terminated parental rights to that child in Wisconsin. Completion of this form meets the requirements of s.48.425(1)(m), Wis. Stats. Another individual may complete this form on behalf of the birth parent if the birth parent is unable to do so. Personally identifiable information on this form is confidential and will be used only for identification purposes.

Instructions: After completion, this form must be attached to and submitted with the "Family History Questionnaire - Medical / Genetic," form CFS-149. If additional space is needed when completing this form, attach separate sheet(s).

Name – Child (Last, First, Middle) / Birthdate – Child (mm/dd/yyyy)
SECTION I / PREGNANCY INFORMATION
1. / When did you first suspect you were pregnant with this child? / 2. / When was this pregnancy confirmed by a pregnancy test?
3. / Yes No Did you receive prenatal care during this pregnancy? / If "Yes", when did prenatal care begin?
4. / Yes No Did you gain weight during this pregnancy? / If "Yes", number of pounds?
5. / Yes No Did you lose weight during this pregnancy? / If "Yes", number of pounds?
6. / Yes No Were you hospitalized during this pregnancy? / If "Yes", list hospitalizations, reasons and dates below.
a. / Hospital / Reason(s) / Dates(s) (mm/dd/yyyy)
b. / Hospital / Reason(s) / Dates(s)
c. / Hospital / Reason(s) / Dates(s)
7. / Yes No Did you take medication during this pregnancy? (Include prescription and over-the-counter or nonprescription drugs.) If "Yes", list them below.
a. / Medication / Purpose of Medication / Date(s) (mm/dd/yyyy) / Dosage Size and Quantity
b. / Medication / Purpose of Medication / Date(s) / Dosage Size and Quantity
c. / Medication / Purpose of Medication / Date(s) / Dosage Size and Quantity
d. / Medication / Purpose of Medication / Date(s) / Dosage Size and Quantity
8. / Yes No Did you smoke cigarettes during this pregnancy? / If "Yes", number per day?
9. / Yes NoDid anyone in your household smoke during this pregnancy?
10. / Yes NoWere you exposed to unusual fumes or other chemicals during this pregnancy (fumes from workplace, hobbies, etc.)? If "Yes", explain; give examples and dates.
11. / Yes NoDid you consume alcoholic beverages during this pregnancy?
If "Yes", specify what kind of alcohol; i.e., beer, wine, liquor, combination.
Drinking Pattern – Complete for each trimester. / 1st Trimester (1 – 3 months) / 2nd Trimester (4 – 6 months) / 3rd Trimester (7 – 9 months)
Binges – Indicate quantity and frequency.
Daily – Indicate quantity.
Other – Occasional; e.g., weekends.
Indicate quantity and frequency.
12. / Yes NoWere you exposed to X-rays during this pregnancy, including dental X-rays? If "Yes", specify when and what body part(s).
13. / Yes NoWere you exposed to other forms of radiation during this pregnancy; e.g., occupational exposure, barium enema / swallow? If "Yes", identify radiation source and dates.
14. / During your pregnancy with this child did you have:
Yes / No
a. / Preeclampsia or hypertension
b. / High blood pressure
c. / Low blood pressure
d. / Albumin or protein in the urine
e. / Diabetes or sugar in your urine
f. / A urinary infection, strange odor or color in your urine
g. / Any vaginal bleeding. If "Yes", specify when and for how long.
h. / Morning sickness. If "Yes", specify when and for how long.
i. / Any immunizations during pregnancy or three months before. If "Yes", specify type:
j. / Any irregular nutrition patterns (special diets). If "Yes", describe:
k. / Fever. If "Yes", specify how high and duration:
l. / Unexplained rashes and / or infections. If "Yes", specify when:
m. / Illness; i.e., chicken pox, mumps, German measles.
If "Yes", specify illness and when:
n. / Any allergies? If “Yes”, specify:
15. / Your Rh factor is: Negative Positive / Your blood type is:
16. / The birth father's Rh factor is: Negative Positive / The birth father’s blood type is:
17. / Medical tests administered during this pregnancy. Check "Yes" or "No" if you were tested for the following.
Yes / No / Date of Test / Test Results
VDRL (syphilis)
Cult / smear (gonorrhea)
Pap smear
Tuberculosis skin test
Herpes
Other sexually transmitted disease tests taken – Specify below.
18. / Diagnostic tests administered during this pregnancy. Check "Yes" or "No" if you were tested for the following. If “Yes” provide date of test and test results.
Yes / No / Date of Test / Test Results
Chorionic Villus Sampling
Amniocentesis
Other Diagnostic Testing completed
19. / Yes / No / Is this your first pregnancy? If "No", complete the following.
a. / Number of past pregnancies, including this one
b. / Number of live births, including this one
c. / Number of miscarriages
Cause of miscarriage(s), if known
d. / Number of stillbirths
e. / Yes / No / Were there complications with the other pregnancies?
f. / Yes / No / Are all the previous live-born children currently living? If "No", age(s) of child(ren) at death:
Cause of death:
SECTION II / DELIVERY INFORMATION
1. / Yes No / Was the delivery vaginal?
2. / Yes No / Were instruments used to assist the delivery?
3. / Yes No / Was the delivery by Caesarian section? If "Yes", what complications led to Caesarian?
4. / How long was the labor? / 1st stage: / 2nd stage: / 3rd stage:
5. / How soon before birth did the membranes break?
6. / Yes No / Did you receive any anesthesia, painkiller or drug to start labor? If "Yes", specify what kind:
7. / The child was: Premature by / weeks. / Post-mature by / weeks.
8. / Yes No / Were there complications with the delivery? If "Yes", specify what kind:
9. / The baby was born: / Feet first (breech) / Head first
10. / Yes No / Was resuscitation or help with breathing required for the child at birth?
11. / Yes No / Was the child jaundiced (yellow) at birth?
12. / Yes No / Was a heart murmur detected at birth?
13. / Yes No / Were any other problems noted AT birth; e.g., any birth defects or handicapping conditions? If "Yes", specify.
14. / Yes No / Were any other problems noted AFTER birth; e.g., any birth defects or handicapping conditions? If "Yes", specify.
15. / Consult the hospital record if the data in Item 15 is not known by the parents.
a. / Birth weight
b. / Birth length
c. / Head circumference
d. / APGAR rating: / One minute: / Five minutes:
e. / Newborn screening: / Positive / Negative / Positive / Negative
PKU / Sickle cell anemia
Maple syrup urine disease / Sickle cell trait
Galactosemia / Cystic fibrosis
Hypothryoidism / Critical congenital heart disease
Hearing loss / Other disorder – Specify:
16. / Yes No / Was more than one (1) baby born at this birth? If "Yes":
a. / How many?
b. / Birth order of this child?
c. / Condition of other baby(s) born during this birth – Specify.
NOTE:IF YOU OR THE AGENCY HAVE ADDITIONAL INFORMATION, ADD SEPARATE SHEETS TO ACCOMPANY THIS FORM.
SECTION III / DISCLOSURE INFORMATION
I authorize the agency assisting in preparing this document to disclose the medical and genetic information in this document to the Circuit Court and to the Wisconsin Department of Children and Families for use in preparing and maintaining the medical and genetic history required by law concerning my birth child named on page 1.
Name – Birth Mother (Print) / Address – Street, City, State, Zip Code (Print) / Telephone Number
SIGNATURE – Birth Mother / Date Signed (mm/dd/yyyy)
Name – Other Person Providing Information (Print) / Address – Street, City, State, Zip Code (Print) / Telephone Number
SIGNATURE – Other Person Providing Information / Date Signed (mm/dd/yyyy)

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